Extension Request Application - Medicaid.gov 2026

1. Click ‘Get Form’ to open the Extension Request Application in our editor.
2. Begin by filling out the 'Applicant Information' section. Enter the date of intake appointment, referral source, applicant ID/SSN, date of birth, gender, and full name. Ensure that your mailing address is complete with city, county, and zip code.
3. In the 'Provider Agency Information' section, input the agency's name, clinician's email address, and contact details including address and telephone number.
4. Proceed to the 'Clinical Information' section. List current DSM5/ICD-10 diagnoses along with any relevant medical conditions. Provide details about medications including dosage and prescriber information.
5. Answer questions regarding treatment history and current risk factors. Be thorough in describing any challenges faced due to mental illness.
6. Finally, ensure that both provider and supervisor signatures are included before submitting the form via mail or fax as indicated at the bottom of the document.

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